HV 13 
.S8 
no. 8 
Copy 1 



LIBRARY OF CONGRESS 



027 273 540 2 






HV 13 
.S8 

no . s ^tufctea in Mortal Work Nmttber B 

CopV 1 EEVISED EDITION FEBRUARY IQl6 



FACTS ABOUT TUBERCULOSIS 



TWENTY-ONE DIAGRAMS 
WITH BRIEF DESCRIPTIVE TEXT 



BY 

LILIAN BRANDT 



price: twenty-five cents 



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UNITED CHARITIES BUILDING 
NEW YORK CITY 

Ctiiected set 



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NOTE 

Through the co-operation of Mr. Louis I. Dublin, 
Statistician of the Metropolitan Life Insurance Com- 
pany, certain errors in computation have been dis- 
covered in the original edition of this pamphlet. These 
have been corrected and advantage has been taken of 
this opportunity to make some changes in the text 
and to add one or two diagrams. The corrections which 
have been made do not materially change the facts pre- 
sented or affect the inferences to be drawn from them. 



* ■ 



HV 13 


.S8 


no. 8 


Copy 1 



INTRODUCTION 

When we start out to get the social facts about the 
extent and distribution and characteristics and ten- 
dencies of any disease, we meet many obstacles. We 
may have in mind a w r ell-rounded and satisfying plan 
for the logical development and comprehensive presen- 
tation of the subject, but we are sure to be thwarted 
at many a step in attempting to carry it out. We find 
ourselves obliged to skip around from year to year and 
from place to place, for illustrations of different points, 
and one alluring aspect after another must be abandoned 
altogether. 

In the first place, the only statistics we have about 
the prevalence of disease, except in the case of con- 
tagious and infectious diseases in some cities, are sta- 
tistics of deaths, and deaths represent illnesses in 
different proportions, almost never completely. 

Next, there are no statistics even of deaths for the 
entire country, for the publications of the Census Office 
since 1902 are wisely restricted by law to those states 
and cities whose records are known to reach a certain 
standard of completeness and reliability. The " regis- 
tration area" for deaths is growing rapidly, under the 
stimulus of the Census Bureau, until in 1913 it included 
twenty-one states and most of the important cities m 
the other states — about two-thirds of the population 
and one-third of the land area of the United States, 
and all varieties of conditions as to composition of 
population, climate, prevailing industries, and other 
circumstances which affect health. 

This very growth, however, is a complication in 



4 FACTS ABOUT TUBERCULOSIS 

studying the tendency in death-rates for the country 
as a whole, for death-rates for the registration area at 
different periods do not relate to the same aggregates 
of population. " Registration area" sounds like the 
same place, whatever the year; but as a matter of fact 
it meant in 1880 only Massachusetts and New Jersey; 
in 1890, New York, New Jersey, New England except 
Maine, Delaware, District of Columbia, and eighty- 
three of the most important cities in other states — 
largely an urban population, including relatively few 
Negroes, and occupying only three per cent of the terri- 
tory of the United States — certainly not representative; 
while the additions since 1900 have added large farming 
areas of the middle west and south and the more popu- 
lous states of the mountain and Pacific coast sections. 
It is difficult, therefore, to get much satisfaction out of 
a decrease in the death-rate of "the registration area" 
since 1890. The Census Bureau publishes such com- 
parisons — unwisely, as it seems to us, for it is not very 
different from comparing the death-rate of Boston in 
1890 with that of Boston and Buffalo combined in 1900; 
Boston, Buffalo, and Indianapolis in 1905; Boston, 
Buffalo, Indianapolis, and Denver in 1910; and Boston, 
Buffalo, Indianapolis, Denver, and St. Louis in 1914. 
It would be more serviceable if we could have in the 
Census reports figures over a series of years for selected 
areas representing different types of conditions and of 
population. 

Another difficulty which has to be faced is that, while 
we now have mortality statistics year by year for a 
large part of the country, we still have a count of the 
population (the other essential element to a death-rate) 
only once in ten years. It is safe enough to estimate 



FACTS ABOUT TUBERCULOSIS 5 

the total population of a city which is growing steadily 
and normally, or of a vast agglomeration of different 
cities and states, like the registration area, in which 
different tendencies may be expected to counterbalance 
one another, in order to get a basis for computing crude 
death-rates in post-censal years ; but for death-rates at 
different ages or for different elements in the population 
it seems wiser to content ourselves with the facts for 
the last census year than to attempt to estimate for the 
years since then. 

In the selection of facts about tuberculosis which 
are here represented we have used figures for the entire 
registration area for the background, and local figures 
for New York City* and some other places for details 
not available for the larger area; figures for 1913 or 
1914 when we do not need death-rates, or when we are 
concerned only with the crude rate, but figures for 1910 
for rates by sex, age, and nationality; figures for cer- 
tain selected localities in considering the decrease that 
has taken place. Rates per 100,000 population are 
used instead of per thousand, in order to make com- 
parisons easier, by avoiding decimal fractions. 

As far as possible the statistics from which the dia- 
grams are made are printed on the diagrams. The 
original figures are to be found, except when other 
sources are mentioned, in the annual Mortality Reports 
of the federal Census Bureau or in the annual reports 
of the Department of Health of New York City. No 
attempt has been made to explain the facts presented, 
since any adequate discussion of them would fill a book. 

* Here we have another complication, in the difficulty of get- 
ting comparable figures before and after the consolidation of 
Greater New York in 1897. 



6 FACTS ABOUT TUBERCULOSIS 

The purpose has been to present those fundamental 
facts about the extent and incidence of tuberculosis 
which are of interest to social workers and to other 
students of social problems. 

The facts are grouped under three general heads: 

(1) the importance of tuberculosis as a cause of death; 

(2) variations in its incidence at the present time, in 
different localities, and according to sex, age, race, and 
occupation; and (3) the decrease that has taken place 
in the death-rate from this disease. 



I 

IMPORTANCE OF TUBERCULOSIS 

In 1910* there were 86,309 deaths from tuberculosis 
in the registration area of the United States, of which 
75,211 were from tuberculosis of the lungs. This means 
a death-rate of 160 per 100,000 population from all 
forms of tuberculosis, 140 per 100,000 from pulmonary 
tuberculosis.! The registration area in 1910 included 
58.3 per cent of the total population of the country. 
Applying the death-rate in the registration area to the 
total population of the country, it seems probable that 
there are something like 130,000 deaths per year in the 
entire country at the present time from pulmonary 
tuberculosis, and 150,000 from all forms of the disease. 
It is generally believed that these figures are an under- 
statement, and the National Association for the Study 
and Prevention of Tuberculosis estimates that a total 
of 200,000 is nearer the truth. 

Assuming, as records in certain cities seem to indi- 
cate, that each death in the course of the year represents 
at least five living cases on any given day, we may con- 
clude that there are probably a million persons suffering 
from some form of tuberculosis in the United States 
at the present time. 

Comparing tuberculosis with other diseases, we find 
that at the present time it is the most important single 
cause of death in the United States. 

* The year 1910 is taken here instead of 1913 in order to avoid 
the necessity of using estimates of population in computing the 
death-rates. 

t Including acute miliary tuberculosis, which is included 
throughout in the figures for tuberculosis of the lungs. 



FACTS ABOUT TUBERCULOSIS 



The first diagram shows how large a section of all 
deaths is due to it, and also what part is played by its 





The Registration Area, 1913. New York City, 1914. 

1. Proportion of Deaths due to Tuberculosis (Black Section). 



two close competitors. The two circles represent the 
total number of deaths in (1) the registration area of 
the United States in 1913, and (2) New York City in 
1914. The black part of each circle represents the 
proportion of deaths due to tuberculosis. 

Tuberculosis was responsible for 10.5 per cent of all 
the deaths that occurred in the registration area in 1913, 
and for 13.8 per cent in New York City in 1914. Pul- 
monary tuberculosis alone, in both the registration area 
and in New York City, was outstripped by organic 
heart disease, and also by pneumonia, if broncho- 
pneumonia be included with lobar pneumonia and 
pneumonia " undefined." In comparing the mortality 
from these three causes, however, it is more logical to 
consider all the deaths caused by any form of tubercu- 
losis, and not merely tuberculosis of the lungs, for we 



FACTS ABOUT TUBERCULOSIS 9 

understand that the disease is identical (i.e., caused 
by the same bacillus and creating the same conditions 
in the tissues) no matter what part of the body is at- 
tacked; while pneumonia, on the other hand, is caused 
by several different bacteria and includes a variety of 
changes in the lungs; and " heart disease" is used to 
represent any organic pathological condition of the 
heart. All three of these leading causes of death are 
relatively more important in New York City than in the 
registration area as a whole. 



II 

VARIATIONS AT THE PRESENT TIME 

The average death-rate of 160 per 100,000 from all 
forms of tuberculosis is far from uniform throughout 
the United States at the present time, or among differ- 
ent groups of the population in any particular locality. 

Comparisons of different localities must be made with 
the greatest caution, because of such considerations as 
those mentioned on page 13. 

States and Cities 
Diagram 2 shows the variations in the twenty-one 
states which were included in the registration area of 



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* Places of 1000 inhabitants and over. 

2. Death-rates from Tuberculosis (All Forms) in the Registration- 
States in 1910. 



10 



FACTS ABOUT TUBERCULOSIS 1 1 

the United States in 1910. Rates which are above the 
average for the entire area are represented by solid 
black columns; those below by the light shading. The 
states are arranged in geographical order, beginning 
at the East. 

Twelve states are below the average; Massachusetts 
comes nearest to it but is slightly above, and the other 
eight are still higher. The states which make the most 
unfavorable showing in this diagram either have a large 
Negro population or contain famous health resorts, or 
both. Except for Colorado and California, the Western 
and Mississippi Valley states have the lowest rates. 
North Carolina's rate (which may be a little exagger- 
ated, since the strictly rural districts are not included) 
is more than six times as high as that of Utah, the 
lowest of all. 

In Diagram 3 we have the fifty largest cities of the 
United States — all the cities that had a population of 
100,000 or over in 1910 — arranged in order according 
to size, and showing their record for pulmonary tuber- 
culosis. 

The black columns represent the rates which are 
above the average (167) for all registration cities dur- 
ing the same period, and the shaded columns those 
which are below. 

As all these cities, except Birmingham, had been 
registration cities during the five years 1906-10, we take 
the average rate for that period, which is more repre- 
sentative than the rate for the single year 1910.* The 

* At the time of going to press the Census Bureau has not yet 
published averages for later periods. 



12 FACTS ABOUT TUBERCULOSIS 

average for the five years is in most cases a little higher 
than the rate for the last year of the period would be. 
Pulmonary tuberculosis is taken in this case, instead of 
all forms, because we have figures for pulmonary tuber- 
culosis in certain foreign capitals, which will be given 
next for comparison with the American cities. 

To account for the height of each of these fifty col- 
umns would require an intimate knowledge of local 
conditions and a great many words. There is no 
apparent relation between the amount of tuberculosis 
in a city and its mere size. 

Some of the circumstances that must be taken into 
consideration in explaining these variations, and the 
differences among the states in Diagram 2, are the com- 
position of the population with respect to age, sex, and 
race (as later diagrams will suggest); the prevailing 
occupations and the housing conditions; whether there 
are hospitals within the city to which large numbers 
of non-residents come, or whether on the other hand the 
main hospital provision for residents is outside the city 
limits; whether there is any psychological influence 
affecting the practice of physicians in reporting the 
cause of death when the patient has had more than one 
disease, or any other factor which might tend to pro- 
duce variations in the records. 

The nineteen foreign cities in Diagram 4 are grouped 
geographically, beginning with those of Great Britain 
and Ireland, going east through Europe, and ending 
with the Australian cities and the one representative of 
South America. The light columns are those which are 
below the average for the registration cities of the 
United States. As has been suggested above, many 
factors enter into these variations, such as, for example, 



FACTS ABOUT TUBERCULOSIS 



13 



New York 


197 


Chicago 


162 


Philadelphia 


206 


St. Louis 


176 


Boston 


175 


Cleveland 


120 


Baltimore 


233 


Pittsburgh 


112 


Detroit 


96 


Buffalo 


126 


San Francisco 


177 


Milwaukee 


114 


Cincinnati 


248 


Newark 


218 


New Orleans 


264 


Washington 


236 


Los Angeles 


252 


Minneapolis 


112 


Jersey City 


203 


Kansas City 


145 


Seattle 


83 


Indianapolis 


186 


Providence 


152 


Louisville 


205 


Rochester 


135 


St. Paul 


106 


Denver 


346 


Portland (Ore. 


) 86 


Columbus 


177 


Toledo 


149 


Atlanta 


183 


Oakland 


158 


Worcester 


134 


Syracuse 


112 


New Haven 


163 


Birmingham 


277 


Memphis 


227 


Scranton 


82 


Richmond 


225 


Paterson 


161 


Omaha 


108 


Fall River 


139 


Dayton 


184 


Grand Rapids 


88 


Nashville 


227 


Lowell 


131 


Cambridge 


238 


Spokane 


93 


Bridgeport 


161 


Albany 


201 



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J. Average Annual Death-rates 1906-10* from Pulmonary Tubercu- 
losis in the Fifty Largest Cities of the United States. 

* Except for Birmingham, in which case the rate is for the single year 1910. 



14 FACTS ABOUT TUBERCULOSIS 

the relatively small proportion of children in the popu- 
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4. Average Annual Death-rates 1906-10 from Pulmonary Tuberculosis 
in Nineteen Foreign Cities. 



City and Country 

In general cities have a higher death-rate from tuber- 
culosis than rural districts, though exceptions may be 



FACTS ABOUT TUBERCULOSIS 



15 



found in particular places, and it is probable that the 
cities as a whole are making more progress than the 
country districts in reducing their mortality. This 
diagram shows the relation between urban and rural 



to 




179 128 195 138 

Cities Rural Cities Rural 

Registration New York 

States State 

5. Urban and Rural Death-rates from Tuberculosis (All Forms) 1910. 

death-rates from tuberculosis in 1910, both for all the 
registration states and for the state of New York. 
Both in New York and in the whole group of regis- 
tration states, the mortality in the rural districts is 
about 71 per cent of what it is in the cities. 



Sex and Age 

Tuberculosis is a more serious cause of death among 
men than among women. The general death-rate of 
women in the United States is more favorable than 
that of men, but there is even more difference in the 
mortality from tuberculosis. 

In the registration area in 1910 tuberculosis was re- 
sponsible for 48,394 deaths of males, and for 37,915 of 
females. The population of the registration area is not 



16 FACTS ABOUT TUBERCULOSIS 

published by sex, and it would be a long task to compile 
it exactly from the figures for the component parts, 
and we cannot, therefore, compute death-rates for males 
and females for the whole area. Taking, however, the 
registration states and the registration cities of 100,000 
inhabitants or more in other states, which includes a 
little territory not yet in the registration area but gives 
us a large proportion of all that is,* we find that the 
males formed about 51.3 per cent of the population in 
1910. Among persons who died of tuberculosis in the 
registration area in that year, about 56.8 per cent were 
males. Putting it another way: the ratio of males to 
females in the population was about 105 to 100, while 
among the victims of tuberculosis it was about 128 to 
100. 

In New York City the difference is even more strik- 
ing. The death-rate from all forms of tuberculosis in 
1910 was 267 for males, while for females it was only 
156, 58 per cent as much. 

The diagram shows the relation (1) of deaths from 
tuberculosis (small inner circle) to deaths from all 
causes (large circle) in New York City in 1910; (2) of 
males and females among those dying from tubercu- 
losis; and (3) of males and females among those dying 
from all other causes. 

The number of males and of females in the popula- 
tion of the city in 1910 was almost the same (about 
2,000 more females). If both sexes died at the same 
rate, therefore, we should have the deaths divided 
about equally — 50 per cent — and the circles would be 

* Registration cities of less than 100,000 inhabitants, in non- 
registration states, are not included, but on the other hand the 
rural districts of North Carolina, which are included, are not a 
part of the registration area. 



FACTS ABOUT TUBERCULOSIS 



17 



divided in two equal parts down the center; whereas 
what we do find is that 63 per cent of all the deaths 




6. Proportion of Males to Females among Deaths from Tuberculosis 
(Small Circle) and among Deaths from All Other Causes in New York 

City, 1910. 

from tuberculosis are deaths of males, and 53 per cent 
of the deaths from all other causes. 

There are great differences in the prevalence of 
tuberculosis at different ages. 

Diagram 7 shows the death-rates from tuberculosis 
in 1911 at successive age-periods,* in the states which 




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7. Death-rates from Tuberculosis (All Forms) by Age Periods, for the 
Year 1911, in the States Constituting the Registration Area in 1900. 



* That is, the ratio between the deaths at the specified ages 
and the population at those ages. 



18 



FACTS ABOUT TUBERCULOSIS 



constituted the registration area in 1900. The highest 
points are reached between 25 and 45; the lowest 
between five and fifteen. 

To supplement this similar figures are presented, in 
Diagram 8, for New York City, bringing out the differ- 




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8. Death-rates from Tuberculosis in New York City bt Age, 1910. 



ences between pulmonary and other forms of tuber- 
culosis. In each column the black part represents pul- 
monary tuberculosis; the shaded part at the top, other 
forms. The age-periods are decades, except that the 
first decade is subdivided in order to show the great 
difference between infancy and childhood. 

The " other forms" of tuberculosis (i.e., chiefly, 
tuberculous meningitis and tuberculosis of the bones 
and of the glands) show their importance in infancy and 



FACTS ABOUT TUBERCULOSIS 



19 



childhood, and to a less degree in old age. The highest 
rate here is found in the period between forty and fifty. 

These diagrams suggest the importance of taking into 
account the age-composition of the population in com- 
paring the death rates of different communities. 

In Diagram 9 the same original tuberculosis figures 
are used as in the preceding diagram, but instead of 




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9. Percentage of All Deaths due to Tuberculosis at each Age-period 
in New York City in 1910. 



comparing them with living population, we now con- 
sider them in relation to the total number of deaths at 
the same ages, in order to discover the relative import- 
ance of tuberculosis as a cause of death at different ages. 



20 



FACTS ABOUT TUBERCULOSIS 



Here each column represents 100 per cent (i.e., all) of 
the deaths at that age. The black part at the bottom 
shows what proportion of all were caused by pulmonary 
tuberculosis, the white part just above represents the 
other forms of tuberculosis, and the rest of the column 
(shaded) represents all the rest of the deaths at that 
age. In the wider column at the right the same facts 
are given for the total population without distinction 
of age. 

The highest death-rate from tuberculosis we found 
(Diagram 8) in the decade 40-49; but we see here that 
it is in the decade 20-29 that tuberculosis is most im- 
portant, in relation to other causes of death, and that 
its relative importance is greater all the way from 10 to 
40 than at 40-49. We notice also that the other forms 




174 387 471 271 
157 218 151 144 



117 20 

107 47 

Under 10-14 15-24 25-44 45-64 65 and 
10 over 



10. Death-rates from Tuberculosis (All Forms) by Sex and Age in 
New York City in 1910 (Males, Black Columns; Females, Shaded). 



FACTS ABOUT TUBERCULOSIS 



21 



of tuberculosis, which were very conspicuous in the 
other diagram in the first five years of life, become in- 
significant here in comparison with other causes of 
death at that age, and on the other hand assume con- 
siderable importance in the ages 5-9 and 10-19. 

In Diagrams 10 and 11 we have a two-fold analysis, 
by sex and by age, of the death-rates from all forms of 
tuberculosis in New York City in 1910 and in a group 
of states in 1911. 

We notice first the great excess in the mortality 
among males, and that the highest rate among women 
comes earlier than it does among men. The latter fact 
is confirmed by the age at death in the registration area, 
which is published by the Census Bureau. The median 
age of all women dying of pulmonary tuberculosis in 



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11. Death-rates from Tuberculosis (All Forms) in the States Con- 
stituting the Registration Area in 1900, for 1911, by Age and Sex 
(Males, Black Columns; Females, Shaded). 



22 FACTS ABOUT TUBERCULOSIS 

1910 was 31.2 years; of all men, 36.6. We see also 
that the tremendous advantage of women is limited to 
the ages after 25. Under 10 and at 15-24 there is not 
much difference between the sexes, and at 10-14 girls 
have a much worse record than boys. 

Diagram 11 gives similar facts, though with different 
age-divisions, for the group of states referred to in 
Diagram 7. The higher rates of girls throughout the 
adolescent period, and the much lower rates of women 
from 35 to 65, are the conspicuous features. 



Race and Nationality 

Diagram 12 shows the extraordinary difference be- 
tween the white and the colored population in the 
registration area in 1910. " Colored 7 ' includes Chinese, 
Japanese, Indians, Hindus, Malays, etc., as well as 
Negroes, but these are relatively few, and the death- 
rate for Negroes alone is probably not very different. 
Both for pulmonary and for all forms the colored 
population has a death-rate more than three times as 
high as that of the white. The difference is a little 
greater in the case of pulmonary tuberculosis than it is 
in the other forms. 

We have not the data for studying the prevalence of 
tuberculosis in detail among the various racial elements 
of the entire registration area, but the next diagram 
(13) shows some of the significant variations in New 
York City in 1910. 

Death-rates for pulmonary tuberculosis have been 
computed for the more important elements in the white 
population, as well as for all the white and all the col- 
ored. The white population is classified according to 



FACTS ABOUT TUBERCULOSIS 23 

the birth-place of parents. Each group, that is, includes 
persons born in the specified country and also persons 




Colored White 
All forms: 450 148 

Pulmonary: 405 129 

12. Death-rates from Tuberculosis of Colored and of White Popula- 
tion in the Registration Area, 1910. 



whose parents were both born there. Each of these 
groups numbered over thirteen thousand in the popu- 
lation in 1910. They are arranged in the order of their 
numerical importance in the population, and the groups 
which have a higher rate than the average for the city 
are represented by solid black columns. 

The highest rate is for the colored, who constitute 
only about two per cent of the population. The Irish, 
however, are not far below, and they are the third in 
numerical importance among these groups of foreign 
parentage. The Germans, second in order of import- 
ance, show a rate that is relatively high, though not 
much over two-fifths that of the Irish. Both the 
German and the Irish element, however, decreased in 



24 FACTS ABOUT TUBERCULOSIS 

actual numbers, as well as in relative importance, be- 
tween 1900 and 1910. The other nationalities with 



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13. Death-rates from Pulmonary Tuberculosis (Exclusive of Acute Mil- 
iary Tuberculosis) Among the White and the Colored, and in Cer- 
tain Elements of the White Population of New York City in 1910. 



relatively high rates are all comparatively small ele- 
ments in the population of the city. 

Remarkably low rates, on the other hand, are found 
among the Russians, Italians, and Austro-Hungarians, 
three elements which have been increasing enormously 
in New York in the last twenty years, until at the pres- 
ent time they form over a third of the total population 
of the city. 



FACTS ABOUT TUBERCULOSIS 25 

Occupation 

We do not know of any recent figures for the general 
population * which show variations in the prevalence of 
tuberculosis in different occupations, but the census 
statistics of 1900 indicated a range of something like 
five hundred per cent among men in fifty-three groups of 
occupations in the registration area as then constituted. 

The 1900 figures are represented on pages 26-7. 
The occupations are arranged in order of their record 
with respect to pulmonary tuberculosis, beginning at 
the top with stone-cutters, cigar-makers, plasterers, 
printers, servants, hat and cap-makers, and clerks, and 
working down gradually to the clergymen, miners, 
farmers, bankers, and brokers at the enviable end of the 
list. Speculations as to why certain occupations are 
found where they are in this diagram might be made to 
fill several pages, but in general the figures correspond 
with what we would expect, considering the nature of 
tuberculosis and the conditions attaching to the various 
occupations. There are no significant rates for women 
in different occupations, so far as we know. 

It is only with much hesitation that we include this 
table about men, for the great variation in ages in the 
different occupations has of course an important bear- 
ing on the death-rates from tuberculosis. It is possible, 
however, to avoid gravely misleading conclusions from 

* Important studies, however, have been made in recent years, 
of the experience of certain labor unions (e.g., printers, photo- 
engravers, potters, and cigar-makers) and the Prudential Insur- 
ance Company has published significant figures from its experi- 
ence of the relative amount of mortality from tuberculosis in 
various " unhealthy' ' trades, especially those in which workers 
are exposed to dusts of different kinds and other irritating sub- 
stances. It is not possible, within the limited scope of this pamph- 
let, to discuss these interesting special studies. 



26 FACTS ABOUT TUBERCULOSIS 

these figures if we keep the differences in age in the fore- 
front of our speculations, and remember, for example, 



Marble and stone cutters 541 

Cigar makers, tobacco workers 477 

Plasterers, whitewashers 453 

Compositors, printers, pressmen 436 

Servants 430 

Hat and cap makers 415 

Bookkeepers, clerks 398 

Laborers (not agricultural) 371 

Tinners and tinware makers 365 

Cabinet makers and upholsterers 359 

Musicians and teachers of music 350 

Glass blowers and glass workers 342 

Barbers and hair dressers 335 

Sailors, pilots, fishermen 333 

Painters, glaziers, varnishers 319 

Leather makers 311 

Apothecaries, pharmacists 306 

Coopers 300 

Plumbers, gas and steam fitters 294 

Masons 294 

Butchers 288 
Saloon and restaurant keepers bartenders, liquor dealers 286 

Liverymen and hostlers 268 

Teamsters, hackmen 261 

Boatmen, canal men 257 

Janitors, sextons 251 

Hucksters, peddlers 251 

Bakers and confectioners 250 

Iron and steel workers 236 

Carpenters and joiners 231 

Engineers and firemen 230 

Leather workers 227 

Tailors 218 

Blacksmiths 213 

Hotel and boarding-house keepers 210 

Textile operatives 208 

Machinists 196 

Architects, artists 189 

Gardeners, florists, etc. 187 

Physicians and surgeons 169 

Merchants and dealers 164 

Engineers and surveyors 145 

Teachers 1 44 

Lawyers 140 

Policemen, watchmen, detectives 137 

Boot and shoe makers 136 

Soldiers, sailors 135 

Collectors, auctioneers, agents 131 

Steam railroad employees 130 

Clergymen 124 

Miners, quarry men 121 

Farmers, planters, farm laborers 112 

Bankers, brokers, officials of companies 92 



14. Death-rates of Men in Fifty-three Groups of Occupations, from 



27 



FACTS ABOUT TUBERCULOSIS 

that a clerk is more apt to be of an age when tuberculosis 
is most prevalent than is a railroad president. 



541 
477 
453 
436 
430 
415 
398 
371 
365 
359 
350 
342 
335 
333 
319 
311 
306 
300 
294 
294 
288 
286 
268 
261 
2.S7 
251 
251 
250 
236 
231 
230 
227 
218 
213 
210 
208 
196 
189 
187 
169 
164 
145 
144 
140 
137 
136 
135 
131 
i30 
124 
121 
112 
92 





1 


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3 


1 


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1 




f 






































































msmmm 


* 


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Pulmonary Tuberculosis, in the Registration Area in 1900, 



Ill 

DECREASE IN THE TUBERCULOSIS DEATH-RATE 

The next six diagrams give some historical informa- 
tion — all too meagre — about tuberculosis in different 
places and in different groups of the population. 

In Diagram 15 we see the decrease that has taken 
place in the death-rate from pulmonary tuberculosis 
in Manhattan and the Bronx (old New York City) in 
the last century, according to figures presented by Mr. 
Frederick L. Hoffman* at the annual meeting of the 
National Association for the Study and Prevention of 
Tuberculosis in 1913. The rates given are the average 
for each decade. 

Records of deaths for the first half of the century 
undoubtedly are not complete, and the real decrease 
must therefore have been greater than that which is 
represented by the statistics. As it stands, however, 
the rate in the first decade of the twentieth century 
is about half what it was at the beginning of the 
nineteenth. There seem to have been two periods of 
decided decrease, at each end of the hundred years, 
while for several decades in the middle of the century 
the rate was almost stationary. This was, as it hap- 
pens, just the time during which the greatest progress 
was being made toward a complete registration of 
deaths, and the stationary appearance may be due 
largely to the inadequate figures for the earlier period. 

There are no satisfactory figures to show what has 
been happening in the United States as a whole, f but 

* Statistician of the Prudential Insurance Company. 
t See page 4. 

28 



FACTS ABOUT TUBERCULOSIS 



29 



all available statistics for individual cities and states 
and foreign countries indicate that the tendency of the 
tuberculosis death-rate everywhere is steadily down- 



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15. Decrease in the Mortality from Pulmonary Tuberculosis in Man- 
hattan and Bronx, by Decades, 1812-1911. 

ward, though in some places the decline is much more 
precipitous than in others. 

Diagram 16 shows the decrease in pulmonary tuber- 
culosis in certain foreign cities (most of those included 
in Diagram 4) by five-year periods from 1881-85 to 
1906-10. With few exceptions each period in each 
city has a lower rate than the preceding period. Paris 
and Dublin show the least improvement; Vienna and 
Sydney — the highest and the lowest at the beginning 
of the period — show the greatest, having reduced their 



30 



FACTS ABOUT TUBERCULOSIS 

rates to less than half (40 per cent and 37 per cent 
respectively) of what they were in 1881-5. 

We have not the data for examining the decrease in 
the various racial elements of the United States, but 



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London Dublin Copenhagen Paris Milan 

16. Decrease in the Mortality from Pulmonary Tuberculosis in Cer- 

Mr. Hoffman, in the paper already quoted, has pre- 
sented figures for pulmonary tuberculosis among the 
white and the colored population of certain Southern 
cities for four successive decades. These are shown in 
Diagram 17, together with the rates in the same decades 
for a group of Northern and Western cities. 

The columns for the Northern and Western cities 
and for the white population of the Southern cities are 
strikingly alike, with a slight advantage on the side 
of the latter group, both in rate of decrease and in 



FACTS ABOUT TUBERCULOSIS 



31 



present status. The death-rate for the colored popula- 
tion of the same Southern cities, on the other hand, has 
not only been much higher than that for the white 







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Munich Vienna Petrograd Sydney Rio de Janeiro 

tain Foreign Cities, by Five-year Periods, 1881-85 to 1906-10. 



throughout the forty years, but it has decreased much 
more slowly, so that the difference between the two is 
constantly widening. 

We have seen that men suffer from tuberculosis more 
seriously than women at the present time. This, how- 
ever, is a recent development. Discussions of this dis- 
ease in the early part of the nineteenth century comment 
on the greater susceptibility of women and explain it 
by their constitutional delicacy and imprudent dress. 



32 FACTS ABOUT TUBERCULOSIS 

It was in the seventies in England that the death- 
rate of females from pulmonary tuberculosis dropped 



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Northern and Southern Cities 

Western White Colored 

Cities 

17. Decrease in the Mortality from Pulmonary Tuberculosis in Fifty 
American Cities, by Decades, 1872-81 to 1902-11. 



below that of the males. We have no general figures for 
the United States and we cannot go very far back in 
New York City, but Mr. Hoffman has compiled the 
rates by sex from tuberculosis (all forms) for Massa- 
chusetts, Rhode Island, and Connecticut combined, 
from 1870 to 1911 (Diagram 18). It starts out well 



FACTS ABOUT TUBERCULOSIS 



33 



above the line for males, and keeps fairly parallel with 
it until about 1885. After that for about ten years they 



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18. Decrease in the Mortality from Pulmonary Tuberculosis among 
Males (Continuous Line) and among Females (Dotted Line) in Massa- 
chusetts, Rhode Island, and Connecticut, 1870-1911. 



run along close together, competing for first place; but 
since 1895 the line for males has been considerably 
higher and the distance between the two seems to be 
widening in recent years, though the difference is not 



34 FACTS ABOUT TUBERCULOSIS 

yet so great as we have found it to be (page 16) in New 
York City. 

Diagram 19 shows what has happened in New York 




1898-1902: 
1908-1912: 

Per cent, 
decrease: 



126 243 481 491 444 
115 176 388 462 295 



9 28 19 6 34 

Ages: Under 15 25-44 65 

15-24 45-64 and 
over 

Males 



94 208 305 217 252 

88 150 215 156 138 



6 28 30 28 45 

Under 15 25-44 65 

15-24 45-64 and 
over 

Females 



19. Decrease in the Mortality from Tuberculosis (All Forms) by Sex 
and Age, in New York City, between 1898-1902 and 1908-12. 



City since the consolidation of 1897, comparing the 
decrease among males and females at different ages. 

We have taken two five-year periods ten years apart, 
centering about the federal census of 1900 and of 1910. 
Unfortunately it is impossible to go farther back in this 
analysis, because of various complications in the avail- 
able records. 

In this diagram the entire column represents the 
death-rate of 1898-1902, the black part that of 1908-12; 



FACTS ABOUT TUBERCULOSIS 35 

the shaded part at the top of each column therefore 
represents what has been cut off in the ten years. The 
males stand at the left, the females at the right. 

At the earlier period the female rate was already 
lower at every age — much lower from twenty-five on; 
and the improvement since then has been considerably 
greater for females than for males — a decrease of 28 
per cent as compared with one of 18 per cent, at all 
ages. Among children there has been comparatively 
little decrease, but more among boys than among girls. 
Among young men and women 15 to 24 years of age 
the rate of decrease has been exactly the same, but over 
25 women have had by far the greater share of the im- 
provement. It is noticeable that the age which has the 
highest rate among men, 45 to 64, shows the least 
decrease. 

It is frequently said that part of the decrease in tu- 
berculosis is only apparent, and is due to the practice 
on the part of some physicians, in places where the 
Board of Health concerns itself actively with this 
disease, to report the death of a consumptive as due to 
pneumonia or chronic bronchitis, when there is any 
excuse for such a report, in order to save the feelings of 
the family because of the fancied stigma attaching to 
tuberculosis, or to enable the landlord to escape the 
expense and the tenant the inconvenience of compul- 
sory disinfection or renovation. This was heard more 
frequently ten years ago, when " administrative con- 
trol^ of infectious diseases was comparatively new. 

By comparing the course of the death-rates from pul- 
monary tuberculosis, pneumonia, and bronchitis, we 
may be able to reach some conclusion as to the degree 
in which this psychological influence has vitiated the 



36 FACTS ABOUT TUBERCULOSIS 

statistics of a particular place. Diagram 20 gives these 
death-rates for old New York City and Brooklyn com- 
bined, for the period beginning with 1868, just after 
the creation of the New York Board of Health. 

The heavy line at the top combines the three rates. 
The line for pulmonary tuberculosis is the lighter con- 
tinuous line, beginning between 300 and 400; the upper 
dotted line represents pneumonia (all forms) ; the lower 
dotted line bronchitis. 

It was in 1894 that the Board of Health first requested 
physicians to report living cases of tuberculosis, as they 
had long been required to report living cases of con- 
tagious diseases, and in 1897 it was made their "duty" 
to do so and systematic efforts were begun to secure 
compliance with the requirement. Now the tuberculosis 
death-rate was already decreasing rapidly, and the 
pneumonia death-rate was already rising rapidly, in 
the eighties, before any such action was taken. The 
sharpest fall in the tuberculosis line comes in the early 
nineties, before the active work of the Board of Health 
set in; and since 1890 all three lines have been falling, 
except for three or four scattered high points for pneu- 
monia, and bronchitis has decreased the fastest and 
seems to be on its rapid way to complete elimination 
as a cause of death. Looking at the combined rate 
for all these diseases, we see that the increase in pneu- 
monia and bronchitis counteracted the decrease in 
tuberculosis until about 1890, but that since then there 
has been a precipitous decline. We may conclude, 
therefore, that in New York, at any rate, the decline 
in the death-rate from tuberculosis is real, or at least 
not secured merely by a transfer to other respiratory 
diseases, and that the influences which are bringing it 



FACTS ABOUT TUBERCULOSIS 37 

about are such as have a favorable effect on the other 
important respiratory diseases. 



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20. Death-rates from Pulmonary Tuberculosis, Pneumonia, and Bron- 
chitis, in (Old) New York City and Brooklyn Combined, 1868-1912. 



We have seen that certain elements in the popula- 
tion of New York City which are increasing rapidly 
have low death-rates from tuberculosis, while certain 
elements with high rates are decreasing in numerical 
importance. 

The final diagram represents an attempt to measure 
the part played in the falling death-rate of New York 



38 FACTS ABOUT TUBERCULOSIS 

City by the changing character of its population. We 
have imagined that the 4,766,883 persons living in New 



407) 


mm ^^ 


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Year 1900 1910 

Death-rate 237 182 

(210) 

21. Actual Death-rates from Pulmonary Tuberculosis in New York 

City, 1900 and 1910, and Estimated Death-rate in 1910 if Composition 

of Population had not Changed. 



York City in 1910 were distributed among the various 
nationalities in the same proportion as they were in 
1900. We have then estimated the number of deaths 
there would have been in 1910, in a population so con- 
stituted, on the basis of the death-rates each element 
in it actually displayed in 1910. 

The net result was 1323 more deaths than actually 
occurred, or an addition of 28 to the death-rate per 
100,000. In 1900 the death-rate was 237; in 1910 it 
was actually 182, but if the population had been con- 
stituted in the same way as it was in 1900, the rate 



FACTS ABOUT TUBERCULOSIS 39 

would have been 210. In other words, of the 55 points 
cut off in the ten years, 28 (over half, the shaded part 
at the top of the second column) may be accounted for 
by the character of the increase in the population, the 
growth of those groups which have a low death-rate 
from this disease, and the relative decline of other 
groups which have a high death-rate. 



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